Cardio-oncology disparities: Interplay of psychosocial stress, inflammation, and cardiometabolic health among Black breast cancer survivors

Abstract

Black breast cancer (BC) survivors have a lower survival rate at every stage of the disease, largely due to a higher BC mortality rate of 41 %, more aggressive forms of BC, cardiovascular comorbidities, and stress related to structural inequities. An underexplored factor is Black women's increased risk for cardiometabolic syndrome (CM), exacerbating cardio-oncology disparities. Many factors associated with increased risk for CM are modifiable through lifestyle behavior interventions and generally fail to improve outcomes among Black women. This lack of efficacy is likely due to the interventions' failure to address the cumulative effects of long-term exposure to psychosocial stressors unique to Black women using cultural frameworks. The protocol design of an 8-week pilot study was presented at the inaugural UF Health Cardio-Oncology Symposium, “Emerging Topics in Cardio-Oncology.” Twenty-six selfreported Black BC survivors will be randomized using a two-group parallel random assignment experimental design, and study details are reported on ClinicalTrials.gov (#NCT05473026). Our primary aim is to assess the feasibility and acceptability of a culturally relevant gratitude journaling intervention to manage stress and promote goalsetting techniques. The second aim is to test the preliminary efficacy of the intervention on stress, inflammatory biomarkers (TNF-α, IL-6, GDF15, CRP), dispositional gratitude, spiritual well-being, and a culturally relevant framework (Superwoman Schema) to examine stressors unique to Black women. If found to be effective, this clinical trial will provide evidence of a viable non-pharmacological intervention for managing psychosocial stressors, improving CM risk, and reducing cardio-oncology disparities.

Black women carry the largest burden of cardio-oncology health disparities. Compared to non-Hispanic White women, Black women have a 41 % higher breast cancer (BC) mortality rate, more aggressive BC sub-types, and increased risk of cardiovascular diseases from cardiotoxic treatment effects and cardiometabolic diseases [1,2]. These disparities are also driven by social determinants of health and an increase in psychosocial distress unique to this population, including sociohistorical and cultural experiences related to race, gender, and class, contributing to cumulative stress and worse cardio-oncology outcomes and behaviors [[3], [4], [5], [6]]. The cognitive, affective, and behavioral responses of Black women to these stressors have been characterized in the five dimensions of a conceptual framework called the Superwoman Schema: the obligations to manifest strength, suppress emotions, resist being vulnerable or dependent, succeed despite limited resources, and help others before themselves leading to these poorer outcomes [6]. To date, behavioral interventions to address cardiometabolic disease risk factors (i.e., obesity, physical inactivity, inflammation, and stress) have generally failed to improve health outcomes among Black women, likely due to not fully considering culture and contextual factors in health. Black women have higher levels of spirituality than non-Hispanic White women. Yet, limited data is known on how mind-body interventions such as mindful gratitude journaling and meditation can improve physical and psychological health and reduce cardiometabolic risk factors [7,8]. It is clear that more research on the psychosocial processes involved in the stress response is needed to understand the biobehavioral pathways to health to close the gap in cardio-oncology health disparities [9].

To help accomplish this goal, the author is the primary investigator of the clinical trial: The Grateful Strides Toward Physical Activity and Well-Being for Black Breast Cancer Survivors (NCT05473026), internally funded by the University of Florida Claude D. Pepper Older Americans Independence Center. This eight-week randomized controlled study evaluates the feasibility of delivering a gratitude journaling intervention to promote physical activity, well-being and positively impact biomarkers of health among Black breast cancer survivors. This culturally relevant intervention also includes a goal-setting component to promote exercise readiness and examine the cultural phenomenon of the Superwoman Schema framework. This trial recently completed enrollment on July 25, 2023, with plans to analyze and disseminate results into clinicialtrials.gov and beyond. Black BC survivors (n = 26) were randomized into either a gratitude or attention control (general memory) group. Study-specific aims include (1) evaluating the feasibility of recruiting and retaining Black BC survivors in a clinical trial and (2) describing the differences and distributions of outcome variables and effect size for the gratitude journaling intervention compared to the attention control group on dispositional gratitude, spiritual well-being, psychological distress, exercise readiness, Superwoman schema subscales, and inflammatory biomarkers (tumor necrosis factor-alpha (TNF-α), growth and differentiation factor 15 (GDF15), and C-reactive protein (CRP)) from baseline to post-intervention. Findings will inform the design and conduct of a large-scale randomized control trial to provide evidence of a viable non-pharmacological intervention for managing cumulative stress and reducing cardiometabolic risk during BC survivorship.

Ethics statement

No animal of human studies are reported in this publication.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.